Total Community Care - Specialists in spinal & neurological care

Providing bespoke care nationwide for clients with spinal injuries and neurological conditions

23 Jun

Spinal Cord Injury Rehabilitation

Spinal cord injury rehabilitation is as complex as the range of needs of an individual and the variety of effect of the huge range of spinal cord injuries.[i]

What is a Spinal Cord Injury?

A spinal cord injury (SCI) is any damage to the spinal cord that results in temporary or permanent changes to movement, feeling, or other nervous system function. An SCI affects these functions at and below the point of the injury. A spinal cord injury can be complete, where there is full loss of nerve function at and beyond the injury, or partial, where some of the bundle of nerves that make up the spinal cord are damaged and some are not, so the injury may result in one-sided or other specific changes in function.

The point of injury and completeness of the damage can vary widely so no two people have quite the same experience of an SCI. The higher up the spinal cord, and the more complete the injury, the more function is lost.

What is Spinal Rehabilitation?

Rehabilitation after a spinal cord injury takes many forms; a multi-pronged approach is necessary to address the range of impact an SCI has on a person’s life and ability[ii]. Every person with an SCI will have a rehabilitation plan based on their individual needs, and that plan will be continually assessed and refined based on changes in need and condition.

The affected person and the extent of the injury are the main factors in determining the type of rehabilitation needed, and the end goal of that rehab. For all people with SCI, the aim of rehabilitation is to support that person in reaching their full physical potential after an SCI, and in learning to live with the new changes and restrictions in their body. The emotional, psychological, physical, and practical aspects of living with an SCI are all important parts of post-SCI care.[iii]

Rehabilitation services and processes are integral to any post-spinal injury care, even where recovery of function is likely to be minimal. A rehabilitation programme is tailored to each patient, and is as variable as the individual and their specific injury. NHS service specifications for best practice in SCI consistently focus on specialised rehab as a key feature of SCI care.

Stages of Spinal Rehabilitation

Spinal cord injury rehabilitation – stages of spinal rehab

Spinal rehab usually begins in hospital, and adapts as a person’s medical condition stabilises. There are some specific stages or milestones following an SCI[iv], although the extent and timing of recovery will vary widely from one person to the next.

  • Immediate treatment: In hospital. For a short period after a traumatic SCI, a condition called ‘spinal shock’ which is a loss or reduction in nerve function – movement, sensation, and autonomic function – immediately following the injury. This is usually the period when the person who suffered the injury is acutely unwell in hospital, and can resolve, whereas physical damage to the spinal cord generally does not. Once someone with an SCI is reasonably medically stable, the rehabilitation process really takes over.
  • First stages of rehabilitation: Depending on the extent of effect of the SCI, the early stages of rehab might take place within a sub-acute hospital setting or specialist neuro rehab centre. While physical functional rehabilitation is ongoing, a person will be continually assessed for extent of recovery, and plans can be made for a plan to get home or to a long-term care or assisted living setting. People with only minor effects from an SCI might get home straight from hospital, but can expect follow-up and to be offered some level of rehab.
  • For the first year or so after an SCI: Follow-up medical and rehab appointments are usually fairly regular, and the frequency depends on a person’s level of need. Support may be in the home, or at an external setting.
  • Long-term: Some aspects of rehab may continue, under the care of a community-based or blended primary and secondary care team. Referral back into more acute rehab services is always an option when there are any changes in condition or ability.

Goals of Spinal Rehabilitation

The ultimate goal of rehabilitation after a neurological event like SCI is to enable the individual to continue to live a life that is as close to their wishes as possible, working around any new changes in function to facilitate that. Rehab goals aim to allow a person to continue their normal activities wherever possible:

  • Work: Returning to one’s former workplace may not be possible after an SCI, but all employers are obliged to make ‘reasonable adjustments’ to enable people with disabilities to continue to work. This could mean flexible or part-time working, or providing accessible premises for work. This is a requirement both for existing workplaces and for recruitment processes, so where someone cannot go back to a physically demanding role, there may be another avenue open for them.
  • Education: Places of education are required by law to assess and make reasonable adjustments for accessibility, and there are schools and colleges that specialise in accessibility and catering for students with complex needs if returning to a former setting isn’t possible.
  • Personal care: Independence is always the goal; that might mean being independent with one’s own activities of daily living, or it might mean filling self-care deficits with supportive carers and equipment. Needing support does not mean losing independence, it just means having different needs to maintain a lifestyle.
  • Social life: Maintaining friendships, interactions with colleagues and those we meet in day-to-day life are all important parts of everyday living. Continuing to see friends and loved ones might take some practical support and adjustments for people with severe spinal cord injuries, but everyone should be able to expect to continue to have a social life.
  • Family Life: Maintaining a person’s position within their family is often reported to be their most important goal.

Father with spinal cord injury in wheelchair surrounded by his childrenFor a parent to continue teaching and playing with their children, for a child to continue to learn and grow and develop their independence, everyone has a role within their family, and continuing that in every way possible after an SCI is the most sensitive and essential part of spinal rehabilitation.

Key Features of Spinal Rehabilitation

Physiotherapy

Physiotherapy is probably the keystone of early and ongoing spinal rehab. Losing control over movement is the aspect of SCI that has the most impact on a person’s day-to-day life, and all their physical needs and processes. Being able to regain any extra functional movement, or to learn the best ways of living with and managing any new challenges to mobility, can make a huge difference for the whole of someone’s life.

Physiotherapy offered after an SCI focuses on the individual’s needs and rehab potential – it could mean functional mobility training learning to walk, grip, and move.[v] Physiotherapists also have significant input with the respiratory needs of a person with an SCI, and chest exercises, cough practice or cough assist devices, and some ventilation support are all largely physio-led.

Physiotherapy can continue for a long time through stages of rehab, and takes the form of an adaptive, individualised care plan. It can include mobility training, strength training, cardiovascular exercise, and stretching and movement practice.

Occupational Therapy

Occupational therapists aim to create an environment which is safe and functional for people with any extra accessibility needs. This can be as extensive as adapted housing, hospital-style beds, hoists and more, or as simple as adapted cutlery for people with reduced grip strength, or grab rails for people at risk of falling.

Orthotics

An orthotist assesses, prescribes, and supplies medical devices that can help with structural changes in the body that affect movement, mobility, and comfort. This can include special supports and braces to help keep feet, ankles, legs, and wrists in the right position to promote movement or prevent problems associated with immobile joints.

Speech and Language Therapy

Speech and language therapy (SALT) is part of spinal rehab and provides support with every challenge that affects communication and swallowing. SALT teams are experienced in helping people bypass challenges with their speech or usual modes of communication. Communication difficulties can be more than speech-based; the way we use our bodies to express ourselves can be complex and the impact of a severely restrictive SCI can be huge. SALT specialists also assess for swallowing difficulties, the need for special texture diets, and more.

Psychology

For most people, an SCI is a traumatic and life-changing event. There is no right or wrong way to feel after something like that, but it’s important that everyone – not just the person directly affected, but the people closest to them too – should be offered any emotional and psychological support they need. Clinical psychologists specialise in the care of people’s mental health through injury and illness, and often specialise in supporting people with very specific conditions.

Dietitian support

Healthy diet to provide extra nutritional needs re spinal cord injury

Not everyone with a spinal cord injury will have extra nutritional needs, but many people with higher SCIs have issues with swallowing, staying nourished and hydrated, and problems with bowel function. Calorie requirements might change with altered ability to exercise, and a good diet can help to reduce any issues around bowel motility and constipation.

Challenges to meeting nutritional needs after an SCI might be as simple as losing the physical ability to shop, make food, and feed oneself; simple problems to overcome with the right support, but insurmountable without it. More complex challenges include losing the ability to safely swallow, control the movement of food in the mouth, and being unable to cough effectively if food or fluid enters the windpipe instead of the oesophagus. Some people with swallowing difficulties after an SCI need to have special tubes like a PEG – a short tube through the abdominal wall straight into the stomach – to bypass swallowing difficulties.

Complex care

Complex care needs that may require to be met after an SCI include support with complex nutritional needs, mechanical ventilation or cough assist devices, and complex continence needs. People with complex care needs might need  24-hour carers, especially those with respiratory ventilation needs.

Ongoing care

Even without complex care needs, many people who have sustained an SCI need some extra support with their normal activities of daily living. Needing extra help getting out and about, performing work and family duties, showering, bathing, washing and dressing is very common, for people with all kinds of conditions affecting their mobility and function. Having support from close family or a more formalised care package can mean that these new needs can be met easily.

The basic nursing care of someone with extra care needs after an SCI can be one of the most important aspects of ongoing life[vi] – without good care, people with reduced mobility and function after an SCI can be prone to serious complications[vii], such as:

  • Skin and tissue damage from pressure and immobility.
  • Challenges with continence, constipation, and urinary tract infections.
  • Malnourishment and dehydration without proper support with meal preparation and feeding or tube feeding management.

Living with a spinal cord injury

Even with a dedicated, specialist rehabilitation team and a comprehensive rehab programme, most people who have a permanent spinal cord injury will always need some extra support in their everyday lives. This can be something as simple as needing some mobility aids or orthotics, very complex care needs like full-time dependence on mechanical ventilation for breathing, or anywhere in between.

Occupational therapy and specialist spinal care teams can help create an environment that’s best suited to an individual’s needs. In that environment, some people may need input from specialist carers and nursing teams to provide part- or full-time support with day-to-day living. Family and loved ones can play an important part in the support of a person with an SCI, but sometimes specially trained, dedicated carers are the best way to meet someone’s support needs.

People who need more complex care, such as the use of breathing equipment, tube feeding, and very specialised mobility equipment, can expect the best possible quality of life, and that might mean

The right rehabilitation, care and equipment means living as fully and independently as possible, filling in any extra care needs to enable anyone with an SCI to focus on the things they really want from life.

[i] Kirshblum, S. C., Burns, S. P., Biering-Sorensen, F., Donovan, W., Graves, D. E., Jha, A., Johansen, M., Jones, L., Krassioukov, A., Mulcahey, M. J., Schmidt-Read, M., & Waring, W. (2011). International standards for neurological classification of spinal cord injury (revised 2011). The journal of spinal cord medicine, 34(6), 535–546. https://doi.org/10.1179/204577211X13207446293695

[ii] Fries J. M. (2005). Critical rehabilitation of the patient with spinal cord injury. Critical care nursing quarterly, 28(2), 179–187. https://doi.org/10.1097/00002727-200504000-00009

[iii] Nas, K., Yazmalar, L., Şah, V., Aydın, A., & Öneş, K. (2015). Rehabilitation of spinal cord injuries. World journal of orthopedics, 6(1), 8–16. https://doi.org/10.5312/wjo.v6.i1.8

[iv] Hachem, L. D., Ahuja, C. S., & Fehlings, M. G. (2017). Assessment and management of acute spinal cord injury: from point of injury to rehabilitation. The journal of spinal cord medicine, 40(6), 665-675. https://doi.org/10.1080/10790268.2017.1329076

[v] Jacobs, P. L., & Nash, M. S. (2004). Exercise recommendations for individuals with spinal cord injury. Sports medicine (Auckland, N.Z.), 34(11), 727–751. https://doi.org/10.2165/00007256-200434110-00003

[vi] Gibson K. L. (2003). Caring for a patient who lives with a spinal cord injury. Nursing, 33(7), 36–42. https://doi.org/10.1097/00152193-200307000-00031

[vii] Sezer, N., Akkuş, S., & Uğurlu, F. G. (2015). Chronic complications of spinal cord injury. World journal of orthopedics, 6(1), 24. https://dx.doi.org/10.5312%2Fwjo.v6.i1.24